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COMPED 2006
Dr. Subhash Agrawal
Senior Consultant, Pediatrician & Neonatologist
Moolchand Hospital & Tirathram Hospital , Delhi
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| Recurrent Abdominal Pain (RAP)
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Common Pediatric Problem, Age : 4-16 yrs.
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Apple’s Definition : Paroxysmal Abdominal pain, Persists> 3 mths., Affects normal activity.
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Chronic pain abdomen : If persists> 6 mths.
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Incidence : Equal till 9 yrs., Then> in Males
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Adolescents : 75% Suffer, 21% severe pain
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Approx. 10% Abdominal pain – Seek medical help
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Mostly in RAP : No identifiable cause
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Exclude organic cause : Before labeling functional etiology.
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| Common Clinical Presentations
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- Isolated paroxysms of abdominal pain
- Abdominal pain ass. With dyspepsia
- Abdominal pain ass. With altered bowel habits
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| Common Organic Causes
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| Clues to an Organic Cause |
- Age : <6 yrs, Pain away from Umbilicus.
- Severe pain – Sudden onset, Sleep disturbed
- Fever, Vomiting, Diarrhea, Blood in stool
- Age : <6 yrs, Pain away from Umbilicus.
- Abdominal distention, Dysuria, jaundice
- Reduced activity, Short stature – Abnormal growth.
- No emotional stress or positive family history
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| Functional RAP |
Also known as
- Psychogenic abdominal pain
- Functional abdominal pain
- Periodic syndrome
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| Functional RAP
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Indicator of psychological disturbances
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High frequency of behavioral disorders
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Evidence of maladjustment, Anxiety reactions
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High strung perfectionists and apprehensive personalities, have no evidence of disease
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Past H/o Colic & feeding problems in infancy
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Family H/o Abdominal pain present
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Stress within the family and/or at school <
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| Functional RAP
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Associated with 5 major paediatric disorders
- Inflammatory bowel syndrome
- Functional dyspepsia
- Abdominal migraine
- Aerophagia
- Functional abdominal pain syndrome
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| Rome II Guidelines – Functional RAP |
Features of Inflammatory bowel syndrome :
- Abnormal stool frequency (>3/d or <3/week
- Abnormal stool form : Lumpy, hard or loose
- Abnormal stool passage : Straining, Urgency, feeling of incomplete defecation.
- Passage of mucus, Bloating, Feeling of abdominal distention.
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| Rome II Guidelines for IBS |
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Child old enough to provide accurate H/O pain
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Pain present for at least 12 wks in previous 12 months – Not necessarily consecutive
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Pain is relieved with defecation or change in stool form or frequency
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No structural/metabolic abnormalities present to explain the symptoms
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| Rome II Guidelines – Functional dyspepsia |
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Pain centered in the upper abdomen (Above Umbilicus) for 12 wks in previous 12 months
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No evidence of organic disease
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Dyspepsia neither relieved by defecation nor by change in stool frequency or form
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Rome II Guidelines – Abdominal migraine |
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3 or more paroxysmal episodes
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Intense, Acute, Midline abdominal pain
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Lasting for 2 hrs to several days
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Intervening symptom free interval : wks to months
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No evidence of metabolic, GI or CNS disease
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Any 2 of the following features presents:
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Headache, confined to one side only
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Photophobia – family history of migraine
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An aura of visual, sensory or motor symptoms
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| Rome II Guidelines – Aerophagia |
Presence of 2 or more of the following:
- Air swallowing Abdominal distention :
- Due to intra-luminal air
- Repetitive belching or increased flatus
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| Rome II Guidelines |
Functional abdominal pain syndrome
- Continuous pain in elderly child or adolescent
- No relation with eating, defecation, menses
- Some loss of daily functioning
- Pain is not feigned
- No other associated organic GI disorder
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| Clues to a Functional Causes |
- Age of onset :> 6 years
- Para-umbilical, midline paroxysmal pain
- No consistent duration, frequency periodicity of pain
- Brief pain with intervals from days to weeks
- Child unable to pin-point the exact site of pain
- No radiation, no relation with meals
- Sleep or pleasure activities – not interfered
- Normal growth, no weight loss, O/E – Normal
- Emotional stress present or positive family history
- RAP children have autonomic nervous system and abnormal intestinal motility
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| Investigations |
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Complete blood counts. Hb, ESR (Raised in IBS)
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Urinalysis and culture, stool-parasites and occult blood.
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Upper GI X-rays, Abdominal ultrasound
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If Peptic Ulcer : H. Pylori antibody test or endoscopy
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If pancreatitis : Serum amylase during active pain
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LFT in suspected hepato – Biliary disorders
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Others : EEG, GI Barium studies, IVP, CT Scan, Cholecystography, Endoscopy & proctoscopy.
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| Treatment – Dietary |
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In IBS : No food rich in fat, alcohol and caffeine
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Avoid high sorbitol high fructose foods as they cause increased gas production and intestinal distention.
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| Cochrane review: |
- Lack of evidence on effectiveness of diet
- Fiber supplements are not effective
- Lactose restricting diets are inconclusive
- Need for well designed trials for dietary interventions in functional RAP.
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| Treatment – Pharmacological |
Cochrane Review
- Recommended drugs : Not very effective
- Lactose intolerance : Lactose fee diet
- Gastro-esophageal reflux : Acid blockers
- IBS & loose stools : Fiber supplementation
- Anticholinergics and Antidepressants : In some patients
- Abdominal migraine : Anti-migraine drugs e.g., Pizotifen Prophylaxis – useful.
- Chronic constipation : Standard treatment
- Close follow up of the patients : Must
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| Treatment – Psychological |
| Cochrane Review |
| Prognosis |
- Many children with RAP : Continue to suffer in adult life from symptoms of IBS
- Poor Prognosis:
- Early development of symptoms
- Delayed treatment
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Last Updated on 15-01-2007
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| How to cite this url |
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Comped 2006 - Conference Abstracts.Pediatric Oncall [serial online] 2007 [cited 15 January 2007(Supplement 1)];4. Available from:
http://www.pediatriconcall.com/fordoctor/Conference_abstracts/
comped/Abdo.asp
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